review article autologous cord blood therapy for infantile...

Review ArticleAutologous Cord Blood Therapy for Infantile Cerebral Palsy:From Bench to Bedside

A. Jensen

Campus Clinic Gynecology, Ruhr-University Bochum, Universitatsstraße 140, 44799 Bochum, Germany

Correspondence should be addressed to A. Jensen; [email protected]

Received 26 September 2013; Accepted 28 December 2013; Published 20 February 2014

Academic Editor: Brian J. Koos

Copyright © 2014 A. Jensen. This is an open access article distributed under the Creative Commons Attribution License, whichpermits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

About 17 million people worldwide live with cerebral palsy, the most common disability in childhood, with hypoxic-ischemicencephalopathy, preterm birth, and low birth weight being the most important risk factors. This review will focus on recentdevelopments in cell therapy for infantile cerebral palsy by transplantation of autologous umbilical cord blood. There are only4 publications available at present; however, the observations made along with experimental data in vivo and in vitro may be ofutmost importance clinically, so that a review at an early developmental stage of this new therapeutic concept seems justified.Particularly, since the first published double-blind randomized placebo-controlled trial in a paradigm using allogeneic cord bloodand erythropoietin to treat cerebral palsy under immunosuppression showed beneficial therapeutic effects in infantile cerebralpalsy, long-held doubts about the efficacy of this new cell therapy are dispelled and a revision of therapeutic views upon an ailment,for which there is no cure at present, is warranted. Hence, this review will summarize the available information on autologous cordblood therapy for cerebral palsy and that on the relevant experimental work as far as potential mechanisms and modes of actionare concerned.

1. Introduction

About 17 million people worldwide live with cerebral palsy,the most common disability in childhood, with hypoxic-ischemic encephalopathy, pretermbirth, and lowbirthweightbeing the most important risk factors [1, 2]. Among 142surviving very low birth weight infants at a corrected age of2 years, there were 23.2% minor and 25.4% severe disabilities[3], from the latter of which 1 in 2 will die before the age of18 years. Furthermore, a metaanalysis revealed that amongchildren with cerebral palsy, 3 in 4 were in pain; 1 in 2 had anintellectual disability; 1 in 3 could not walk; 1 in 4 could nottalk; 1 in 4 had epilepsy; and 1 in 10were blind [2].This reflectsthe magnitude of the personal, medical, and socioeconomicburden of this devastating brain disorder [4]. In the UnitedStates the estimated lifetime costs to society for treatmentand care for persons born in 2000 with cerebral palsyamount to US$ 11.5 billion [5]. Thus, causative treatmentsalong with definition of responsive brain disorders, timingof intervention, and definition of risk groups are needed toprevent the sequelae of infantile cerebral palsy.

This review will focus on recent developments in celltherapy for infantile cerebral palsy by transplantation ofautologous umbilical cord blood because therapeutic strate-gies using cord blood in other human neurologic entities,including those for lysosomal storage disorders [6], haverecently been reviewed elsewhere [7–10]. There are only 4publications on autologous cell therapy available at present;however, the observations made along with experimentaldata in vivo and in vitro may be of utmost importanceclinically, so that a review at an early developmental stageof this new therapeutic concept seems justified. Particularly,since the first published double-blind randomized placebo-controlled trial in a paradigmusing allogeneic cord blood anderythropoietin to treat cerebral palsy under imunosuppres-sion showed beneficial therapeutic effects in infantile cerebralpalsy [11]. Thus, long-held doubts about the efficacy of thisnew cell therapy, that were in part related to the “homing”mechanism, are dispelled and a revision of therapeutic viewsupon an ailment, for which there is no cure at present, iswarranted.

Hindawi Publishing CorporationObstetrics and Gynecology InternationalVolume 2014, Article ID 976321, 12 pageshttp://dx.doi.org/10.1155/2014/976321

2 Obstetrics and Gynecology International

However, transplantation of allogeneic cord blood forcerebral palsy is limited by immunologic responses of the host(host-versus-graft reaction) and therefore requires immuno-suppression, which in turn causes both inflammatory andneurotoxic side effects as well as reduced therapeutic efficacydepending on the degree of HLA mismatch [11, 12]. Hence,this review will summarize only the available informationon autologous cord blood therapy for cerebral palsy andthat on the relevant experimental work as far as potentialmechanisms and modes of action are concerned.

2. Preclinical Studies

2.1. Human Umbilical Cord Blood Cells “Home” and PreventSpastic Paresis. First mention of the concept of ameliorationof perinatal brain damage by neuroregeneration using cordblood dates back to 2002, when our preliminary data inchronically prepared fetal sheep showed a highly specificinvasion of human umbilical cord blood mononuclear cells(huMNC) into the damaged brain region, that is, “homing,” ina model of cerebral ischemia [13].This was the beginning of aseries of experiments in vitro and in vivo, using a different ani-mal model (“Levine”) of perinatal cerebral hypoxic-ischemiain newborn rats to increase effectiveness [14, 15].The “Levine”model includes unilateral carotid artery ligation followed by8% O

2inhalation for 80 minutes on postnatal day (PN) 7.

The neurodevelopment of the rat at PN 7 is equivalent to thatof the human brain at birth [16]. These studies yielded threemajor insights. First, the confirmation that unmanipulatedhuMNC transplanted systemically 24 hours after the insultinvade the damaged brain area in large numbers in a highlyspecific manner (“homing”), as observed in the sheep model[13]. Unlike in the latter (transplantation into the umbilicalvein), in the rat model we had chosen to transplant themononuclear cells intraperitoneally [14], thus providing theunique opportunity to observe that these cells migrate longdistance to the damaged area when appropriate signals arereleased [17] (Figure 1). Secondly, this “homing” of huMNCwas strictly confined to hypoxic-ischemic regions showingmicroglial activation, assessed immunohistochemically byCD68 expression, along with signs of apoptotic activity,assessed by cleaved caspase-3 expression. Not one singlehuMNC was found elsewhere in the brain. There is growingevidence that among others inflammatory-mediating effectsand mesenchymal stem cells are involved [18]. Thirdly, andmost importantly, we observed that huMNC transplantedsystemically after cerebral hypoxic-ischemia prevented thedevelopment of spastic paresis [17] (Figure 2). If to whetherthis involved prevention and/or restoration of white mat-ter damage and how oligodendrocytes might be protected,remains to be established [19, 20]. It is important to noticethat these effects were demonstrated in an acute treatmentparadigm transplanting huMNC shortly after the insult.There is, however, no information as yet on the efficacy of adelayed treatment and how this may rate limit the effects ofcells on the development of the functional connectome [21].

2.2. Cord Blood Cells Release Growth Factors, Cytokines, andChemokines. Studies in vitro revealed that among others

Figure 1: Intraperitoneal transplantation of mononuclear hUCB-derived cells resulted in a specific “homing” of these cells into theCNS and incorporation around the lesioned area. Title page from[17, Figure 3(B)]. HLA-DR-positive mononuclear cells (green) arelocated within a scaffold of GFAP-positive astrocytes (red) in thearea of the hypoxic-ischemic lesion. This paper is available onlineat: http://www.nature.com/pr/journal/v59/n2/full/pr200649a.html.

a number of growth factors, anti-inflammatory cytokines,and chemokines are released from huMNC upon stimulation(Figure 3) [22].This supported the concept that the “homing”of these cells into the damaged brain area may exert indirectbeneficial effects rather than replace neurones, for example,by transdifferentiation, as it was speculated in the firstplace. In fact, in our hands, unlike in others also usingrats [23, 24], there was no evidence for transdifferentiation.However, the most intriguing finding beyond “homing” wasthat in newborn rats transplantation of huMNC after cerebralhypoxic-ischemia prevented spastic paresis, the key symptomof cerebral palsy in animals as well as in humans [17]. Thiseffect was independent of the site of transplantation, thatis, intraperitoneal or intrathecal [25], but the mechanismsinvolved in functional neuroregeneration are unknown.

2.3. The Chemokine SDF-1 Promotes “Homing”. As far asmechanisms andmodes of action are concerned, chemokinespromoting “homing” are of major interest [26]. Amongothers, stromal derived factor (SDF)-1, expressed in thedamaged brain region, plays a significant role by bindingto the CXCR4-receptor on huMNC. This in turn elicitslong distance migration of these cells to the damaged brainregion. The finding that in newborn rats SDF-1 is a majorchemokine involved in this mechanism is supported byreceptor blocking experiments using monoclonal antibodiesthat showed prevention of “homing” to a large extent [26].The residual “homing” observed may well be caused by dif-ferent chemokines released from huMNC [22], for example,MIP-1 alpha or MCP-1 (Figure 3), as shown in the adult ratstroke model [27]. However, there are also other mechanismsto consider.

Obstetrics and Gynecology International 3

1.3

1.2

1.1

1

0.9

0.8

0.7

0.6

n.s.n.s.n.s.

Toe d

istan

ce1–5

(cm

)

Con

trol

Con

trol

+tr

ansp

lant

atio

n

Hyp

oxic

-isch

emic

lesio

n

tran

spla

ntat

ion

Hyp

oxic

-isch

emic

lesio

n+

∗∗∗

(a)

5

6

7

8

9

10n.s. n.s. n.s.

Step

leng

th (c

m)

Con

trol

Con

trol

+tr

ansp

lant

atio

n

Hyp

oxic

-isch

emic

lesio

n

tran

spla

ntat

ion

Hyp

oxic

-isch

emic

lesio

n+

∗

(b)

Figure 2: Transplantation of hUCB-derived mononuclear cells reduces spastic paresis as assessed by footprint analysis of 3-wk-old animals(see [17, Figure 5]). (a) Hypoxic-ischemic brain damage results in spastic paresis of the distal limb muscles, causing a significant reductionof footprint width (toe distance 1 to 5) of the right hind paw (contralateral to the insult; black columns) compared with the left (ipsilateral;gray columns) hind paw. Intraperitoneal transplantation of hUCB-derived mononuclear cells after hypoxic-ischemic brain damage reducedspastic paresis. In these animals, differences between ipsi- and contralateral hind paws were no longer detectable. Photographs of footprints(right hind paws) illustrate the footprint widths (arrows) of control animals without (left) and with (center left) transplantation, uponhypoxic-ischemic lesion without (center right) and with (right) transplantation of hUCB-derived mononuclear cells. (b) In control animalswith and without transplantation, the step length of left and right hind paws is equal. In contrast, hypoxic-ischemic lesion resulted in asignificantly reduced step length of the right hind paw (black columns) compared with the left hind paw (gray columns). This reductionin step length of the hind paw contralateral to the lesion, also indicative of spastic paresis, was largely alleviated upon transplantationof hUCB-derived mononuclear cells. Data are presented as mean ± SEM; ∗𝑃 < 0.05; ∗∗∗𝑃 < 0.001. This paper is available online at:http://www.nature.com/pr/journal/v59/n2/full/pr200649a.html.

2.4. Cord Blood Cells Reduce Glial Scars and Restore CorticalNeural Processing. As shown in a recent study on cerebralhypoxic-ischemia in newborn rats, transplanted huMNCcause a reduced glial activation along with reduced gapjunction proteins (CX43), thus reducing glial scar formation[25] so that neuroregenerative processes may be entrainedto such an extent that even neuroprocessing in the primarysomatosensory cortex recovers [28]. Specifically, it has beenshown in the same model that the dimensions of corticalmaps and receptive fields, which were significantly alteredafter brain damage, were largely restored, and hyperexcitabil-ity was no longer observed in huMNC treated animals,as indicated by a paired-pulse behavior, resembling thatobserved in control animals [28]. The beneficial effects oncortical processing were reflected in an almost completerecovery of sensorimotor behavior. Thus, huMNC reinstallthe way central neurons process information by normalizinginhibitory and excitatory processes [28] (Figure 4).

But not only the somatosensory motor behavior, alsogross and finemotor function as well as muscle strength wereimproved upon transplantation of huMNC after hypoxic-ischemic brain damage in newborn rats both medium andlong term [25].These beneficial effects are independent of thetransplantation site. This holds also true for the fore limb use

bias in the long term, an index to describe the lateralizationof the limb use towards the healthy side after hypoxic-ischemia during erection of the animals in a perspex cylinder.Interestingly, therewas a clear time course of recovery, in that,unlike spasticity [17], the fore limb bias was still significantlydifferent from control at 2 weeks (P21), but not at 6 weeks(P51) after transplantation [25].

Glial cells play a crucial role in neuroregeneration,specifically, activation of astrocytes as part of the inflam-matory response may be involved in the formation of glialscars that limit neuronal plasticity after brain damage innewborn rats [25]. This response also led to accumula-tion of activated microglia/macrophages as indicated byincreased CD68 (ED1) expression, a lysosomal protein anda member of the LAMP4 family, allowing “homing” ofmacrophage subsets to particular sites where the tissuedamage is most pronounced (http://www.genecards.org/cgi-bin/carddisp.pl?gene=CD68). Interestingly, the CD68 (ED1)immunosignals in brain regions representing cortical motorareas for fore and hind limbs were significantly smallerin transplanted animals, an effect that was long-lasting (6weeks) and irrespective of transplantation site of huMNC[25, 29], suggesting that the blood brain barrier had noinfluence on these effects in this model. In line with


1

2

3

4

5

6

7

8

a b c d e f g h i j k

(a)

1

2

3

4

5

6

7

8


(b)

1

2

3

4

5

6

7

8


Pos Pos Pos Pos

Pos Pos

Neg Neg

Neg

ENA-78 GCSF GM-CSF GRO GRO-aI-309 IL-1a II-1𝛽 IL-2 IL-3 IL-4 IL-5 IL-6 IL-7 IL-8 IL-10IL-12 IL-13 IL-15 IFN-g MCP-1 MCP-2 MCP-3 MCSF MDC MIG MIP-1𝛽

MIP-1d Rantes SCF SDF-1 TARC TGF-𝛽1 TNF-a TNF-𝛽 EGF IGF-1 AngOSM Tpo VEGF PDGF-B Leptin BDNF BLC Ck𝛽 8-1 Etx Etx-2 Etx-3FGF-4 FGF-6 FGF-7 FGF-9 Fit-3 Lig. Fract GCP-2 GDNF HGF IGFBP-1 IGFBP-2IGFBP-3 IGFBP-4 IL-16 IP-10 LIF Light MCP-4 MIF MIP-3a NAP-2 NT-3NT-4 Osteoprot PARC PIGF TGF-𝛽2 TGF-𝛽3 TIMP-1 TIMP-2

(c)

Figure 3: Protein antibody array detecting cytokines in human umbilical cord blood (hUCB)-cell conditioned media (see [22, Figure 7]).Representative examples of two antibody array membranes, incubated with either nonconditioned culture medium (a) or culture mediumconditioned by hUCB-derived mononuclear cells for 2 days (b). Increasing intensity reveals increased secretion of the cytokines investigated.Dots a1 to d1 and j8 to k8 were positive controls (Pos); dots e1 to f1 and i8 were negative controls (Neg). (c) Overview of all proteinsassayed on the membrane. Boxed factors are color-coded and refer to those proteins secreted at significant levels. Colors designateinterleukin proteins (purple), growth factors (blue), chemokines (yellow), as well as tissue inhibitors of metalloproteinase2 (TIMP-2)(orange). Ang: angiogenin; BDNF: brain-derived neurotrophic factor; BLC: B-lymphocyte chemoattractant; EGF: epidermal growth factor;ENA-78: epithelial neutrophil-activating protein-78; Etx; eotaxin; FGF; fibroblast growth factor; Fract: fractalkine; GCP-2: granulocytechemotactic protein-2; GCSF: granulocyte colony-stimulating factor; GDNF: glial cell-derived neurotrophic factor; GM-CSF: granulocytemacrophage colony-stimulating factor; GRO: growth-regulated oncogene; HGF: hepatocyte growth factor; IFN-g: interferon-g; IGF-1:insulin-like growth factor-1; IGFBP: insulin-like growth factor binding protein; IL: interleukin; IP-10: interferon-inducible protein-10; LIF:leukemia inhibitory factor; MCP: monocyte chemoattractant protein; MCSF: macrophage colony-stimulating factor; MDC: macrophagederived chemokine; MIF: macrophage inhibitory factor; MIG: monokine induced by g-interferon; MIP: macrophage inflammatory protein;NAP-2: neutrophil activating protein-2; NT: neurotrophin; OSM: oncostatinM;Osteoprot: osteoprotegrin; PARC: pulmonary and activation-regulated chemokine; PDGF-B: platelet-derived growth factor-B; PIGF: placenta growth factor; SCF: stem cell factor; SDF-1: stromal-derivedfactor-1; TARC: thymus associated and regulated chemokine; TGF-b: transforming growth factor-b; TNF: tumor necrosis factor; TIMP: tissueinhibitor of melloproteinases; Tpo: thrombopoietin; VEGF: vascular endothelial growth factor.

a reduced activation of microglia/macrophages, there wasalso a reduced astrocytic glial fibrillary acidic protein (GFAP)immunoreactivity, suggesting both diminished inflammatoryresponse and glial activation after transplantation [25].

The distribution of gap junction protein CX43 reflectedthat of GFAP, while a zone of upregulation was observedin the inner glial wall of astrocytes and microglia, whichseparated the lesion core from the surrounding parenchyma.Again there was a reduced CX43 expression after huMNCtransplantation, suggestive of less glial scar formation. Theobserved changes were quantified by Western blot analysisand quantitative real-time PCR of GFAP and CX43 onproteins and mRNA at 1 day (P9), 2 weeks (P21), and 6

weeks (P51) after transplantation, revealing already after1 day a downregulation of astrocytic protein and mRNA[25] (Figure 5). These results were confirmed by quantitativeanalysis of src-homologous phosphotyrosine phosphatase1 (SHP-1) expression, a protein known to be associatedwith reduced astroglial proliferation. Unlike in animals afterhypoxic-ischemia without treatment, in transplanted animalsSHP-1 was reduced to control levels after initial elevation[30, 31].

In summary, transplantation of huMNC reduces glialscar formation and improves motor deficits medium andlong term after hypoxic-ischemia in the newborn rat.This is paralleled by reduced infiltration of activated


2.0

1.6

1.2

0.8

0.4

0

Map

size

(mm2)

Control Lesion Lesion + hUCB

Right hemisphereLeft hemisphere

∗

∗

100

80

60

40

20

0

Rece

ptiv

e siz

e (m

m2)

Control Lesion Lesion + hUCB

Right hind pawLeft hind paw

∗∗

∗

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Figure 4: Effects of hypoxic ischemic brain injury and hUCB treatment on receptive field (RF) and cortical map size (see [28]). (a) Inlesioned rats the size of the left cortical hindpaw (HP) representation was significantly reduced after hypoxic ischemic brain injury (HI)(𝑃 = 0.005 versus controls, 𝑃 = 0.004 versus contralateral hemisphere). Treatment with hUCB cells prevented map changes in the leftcortical HP representation. (b)–(d) images of the cortical surface of the left hemisphere of a control (b), lesioned (c), and hUCB treatedrat (d). Numbers indicate penetration sites; x indicates noncutaneous responses. hl: hindlimb. Borders of the maps are outlined. Scalebar 1mm. (e) In lesioned rats RF size of the right HP was increased (𝑃 = 0.007 versus controls, 𝑃 = 0.03 versus HP ipsilateral to thelesion). hUCB treatment leads to moderate RF increase, not significantly different from controls (𝑃 = 0.558). Bars represent sem (f)–(h)examples of RFs on the right and left HP for a control (f), lesioned (g), and hUCB treated rat (h). Number of rats used: control group𝑛 = 10, lesion group 𝑛 = 17, and hUCB group 𝑛 = 6. A total of 975 RFs were recorded (left hemisphere: control 127: lesioned 97, treated85; right hemisphere: control 192, lesioned 327, and treated 147). doi: 10.1371/journal.pone.0020194.g003. This paper is available online at:http://www.plosone.org/article/info:doi/10.1371/journal.pone.0020194.


P21

(a) (b) (c) (d) (e)

P51

(f) (g) (h) (i) (j)

(k) (l)

Figure 5: Reduction of microglial infiltration and GFAP expression after hUCB transplantation (see [25]). Schematic drawings showrepresentative coronal brain sections after hypoxic-ischemic lesion corresponding to Bregma þ1.2-(þ) 0.2 mm at P21 (a) and P51 (f). Boxeshighlight photographed areas (green: CD68 expression in the basal ganglia; red: GFAP expression in the cortex). (b) HI led to an infiltrationof CD68 positive microglia. Cells were present at the lesion site throughout the late acute ischemic (P21) and, to a lesser extent, in thechronic postischemic phase ((g) P51). Dotted lines delineate histological defined areas of prominent tissue damage, and these express higherlevels of CD68. Long white arrows indicate clusters of CD68 positive cells. Brains of transplanted animals showed a reduced microglialinfiltration at both time points compared to nontransplanted animals ((c) P21; (h) P51). In analogy, two weeks following HI a massiveupregulation of GFAP encircling the lesion site was observed (d) and maintained until seven weeks of age (i). hUCB transplantationled to a reduced amount of GFAP immunoreactivity around the ischemic zone ((e) P21; (j) P51), thus leaving a larger portion of theremaining cortex spare of the inflammatory reaction ((e) and (j) white dotted line indicates border of cortical areas with lower versusthose with higher GFAP expression). Astrocytes in the vicinity of the ischemic zone presented an activated phenotype characterized by alarge soma and fewer processes, thus obtaining a more rounded shape ((k) white arrows). In hUCB transplanted animals, a higher numberof astrocytes appeared to have a more elongated phenotype with long processes ((l) white arrows). Scale bars: 50𝜇m. (For interpretationof the references to color in this figure legend, the reader is referred to the web version of this paper.) This paper is available online at:http://www.sciencedirect.com/science/article/pii/S0006899312011511.

microglia/macrophages and decreased expression of GFAP,CX43, and SHP-1 mRNA and protein, all of which are knownto increase after hypoxic-ischemia [32–34]. Importantly,reduced scar formation might be a prerequisite of functionalneuroregeneration, that is in part mediated by T cells in theumbilical blood [35, 36].

2.5. Neuronal Survival. The mechanisms by which trans-planted huMNC exert functional recovery in the brain

are largely unknown. Hence, studies on the cellular andmolecular level are required. Recently, using our modelof hypoxic-ischemia in newborn rats [17], the effects ofhuMNC transplantation on apoptosis, the number of vitalneurons, expression of neurotrophic and angiogenic factors,and on the integrity of the blood brain barrier have beenexamined [37]. Specifically, cleaved caspase-3 and neuronalnuclei protein Neu-N expression, markers for apoptotic celldeath, have been quantified using immunohistochemistry


and immunoblot analysis. There was clear evidence forimproved neuronal survival caused by huMNC transplanta-tion after brain injury.

Furthermore, expression of brain-derived neurotrophicfactor (BDNF) and vascular endothelial growth factor(VEGF) revealed already two days after the insult that bothgrowth factors, known to inhibit apoptosis and inflammation(BDNF) and to promote vasodilatation, angiogenesis, andneuroprotection (VEGF), declined in untreated but showedno change (BDNF) or an increase (VEGF) in transplantedanimals [37]. Thus, both growth factors may contribute toneuroprotection [38] by neurotrophic and proangiogenicaction [39].

2.6. Blood Brain Barrier. In our first set of experimentson transplantation of huMNC after hypoxic-ischemic braindamage in newborn rats, we hypothesized that—unlikein control animals that received a transplantation withoutbrain lesion—the blood brain barrier must have been atleast transiently destroyed [17] to explain the “homing” ofhuMNC into the damaged brain area in large numbers[40]. This would lead to a “facilitated intrusion of MNCand a preferential regional incorporation of these cells”[17]. To test this hypothesis, the changes in expression oftight junction protein occludin, a marker for blood brainbarrier integrity, and angiopoietin receptor tyrosine-kinasewith immunoglobulin-like and EGF-like domains (Tie)-2,an endothelial protein associated with angiogenesis, werestudied immunohistochemically and by immunoblot analysis[37]. There was clear evidence for a breakdown of the bloodbrain barrier, indicated by decreased expression of occludintwo days after the insult (P9), followed by an increaseof occludin to control levels at 2 weeks (P21), suggestingmolecular reconstruction of the blood brain barrier at thispoint. Similarly, there was clear evidence of increased expres-sion of Tie-2 protein levels after transplantation of huMNC,suggesting vascular regeneration and angiogenesis after theinsult by the transplanted cells [37, 41]. Thus, the proposedhypothesis of transient breakdown of the blood brain barrieralong with vascular cerebral impairment as a basis for the“homing” process has been supported [17]. However, it hasnot been tested if the breakdown of the blood brain barrieris essential for “homing” or a coincidental event. Further,the fact of reconstruction of the blood brain barrier at twoweeks after the insult is potentially at variance with clinicalobservations showing improved outcome after (very) delayedtreatment. This raises the important issue of whether humanumbilical cord blood mononuclear (stem) cells can cross theintact blood brain barrier.

3. Autologous Cord Blood Transplantation inInfantile Cerebral Palsy

Clinical data on autologous cord blood transplantation fortreatment of cerebral palsy are scarce [42–45] and have largelybeen collected for safety and feasibility reasons. There is onlyone videodocumented case of autologous cord blood trans-plantation after severe global hypoxic-ischemic brain damage

Figure 6: First autologous cord blood transplantation after globalhypoxic-ischemic brain damage caused by cardiac arrest in a boy 2.5years of age (see [43]). Nine weeks after the insult the patient (L. B.)received an autologous cord blood transplantation to treat cerebralpalsy (January 27, 2009). The boy was normally developed whenbrain damage occurred, that was followed by a quadriplegic persis-tent vegetative state (see video S3 in Supplementary Material [44]).From left to right: A. Jensen, M. D.; patient L. B.; E. Hamelmann,M. D., Ruhr-University Bochum, Germany. This paper is availableat: http://www.campus-klinik-bochum.de/pdf/Jensenrm12011.pdf.

caused by cardiac arrest, leaving the 2.5-year old boy in aquadriplegic persistent vegetative state [43, 44] (Figure 6).Accordingly, MRI revealed signal hyperintensity in both theentire cortex and basal ganglia (Figures 7(a), 7(b), and 7(c))(see also video S1, S2 in Supplementary Material [44]), andEEG rhythm and frequency were grossly disturbed showingtransient isoelectric traces. On the day of transplantation, 9weeks after the insult, the boy presented quadriplegic cerebralpalsy (see video S3) [44]; his pupils were still dilated showingonly minimal response to direct light (Figure 8). He wasblind (cortical blindness), deaf, and whimpered permanently.One week after transplantation he stopped whimpering, at 4weeks he executed simple tasks on demand, motor controlimproved, and spastic paresis was largely reduced [43]. At7 weeks, EEG was normal and eyesight recovered in part;he started smiling when played with (Figures 9(a), 9(b),and 9(c)) and was able to sit with support and to speaksimple words (Ma-ma, Pa-pa) (see video documentation,S4) [44]. At 1 year after transplantation, spastic paresiswas further reduced free sitting and walking with supportwere possible. After 2 years, there was independent eating,crawling, passive standing, and walking in a gait trainer(see video documentation S5) [44]. Fine motor control hadimproved to such an extent that the boy managed to steer aremote control car (see video documentation S6) [44]. After3 years, receptive and expressive speech competence alsoimproved significantly (four-word sentences, 200words), andthere was broad understanding [44]. Now, at the age of 7 and4.5 years after transplantation, the boy has entered primaryschool (Figure 10), though still using a posterior gait trainerfor ambulation (Crocodile Retrowalker).

Papadopoulos and coworkers first reported on 2 toddlerswith diagnosed cerebral palsy that received a combination ofautologous cord blood, low dose subcutaneous granulocytecolony stimulating factor (G-CSF) injection before and/orafter cord blood transfusion, and hyperbaric oxygen therapy


(a) (b) (c)

Figure 7: BrainMRI of the patient (L. B.) 2 weeks after cardiac arrest. Note, signs of severe global ischemia in cortical structures as evidencedby (a) signal hyperintensity of gyri in almost entire cortex (FLAIR sequences) and basal ganglia (b), including caudate nucleus and putamen(c) (FLAIR DWI sequences with contrast media) (see video S1, S2 in Supplementary Material [44]).

Figure 8: EEG recording (L. B.) before transplantation. EEGrecording. The patient (L. B.) is in a persistent vegetative state 9weeks after the insult before transplantation of cord blood cells.Note, the dilated, unresponsive pupils in spite of bright light fromthe ceiling (see video S3 in Supplementary Material [44]).

[42]. Though there were no abnormalities in MRI imagingbefore and after treatment and both experienced uneventfuldeliveries at term by caesarean section with normal Apgarscores and weights without obvious signs of obstetrical riskfactors, the toddlers presented spastic diplegia and wereunable to walk at 19 months (case 1) and 15 months (case 2),respectively, the latter only being able to stand briefly usingorthosis. Both toddlers were classified as level III in the GrossMotor Function Classification System (GMFCS). In bothcases significant improvements inmotor ability were noted at7 weeks and at 36 months after cord blood transfusion withreduced spasticity bilaterally, allowing them to walk almostindependently, to run (case 1), and to swim. In both casesreclassification to GMFCS level I was possible [42].

The largest cohort of autologous cord blood transplan-tation for cerebral palsy has been published by Lee andcoworkers [45], who reported on an uncontrolled single armpilot study of 20 children with cerebral palsy to assess thesafety and feasibility of the procedure as well as its potential

treatment efficacy (see Table 1, [45]). In this carefully doc-umented study, employing an array of neurodevelopmen-tal examinations and imaging techniques, including brainperfusion SPECT analysis and MRI-DTI (FA values) beforeand during follow-up, there were overall neurologic improve-ments in 5/20 children, ranging from 23 to 91 months of age,weighing 7.2–21.4 kilogram (Table 1) [45]. Interestingly, thetype of cerebral palsy exhibitedmattered, in that patients withdiplegia or hemiplegia showed improvements rather thanthose with quadriplegia.

From these 5 children, MRI FA values were evaluated toassess white matter integrity in 26 regions of interest (ROI).In 3 regions (temporal right, corpus callosum, and rightposterior periventricular white matter) significant changesafter treatment were noted when compared with pretreat-ment values. The authors conclude that intravenous cordblood infusion seems to be practical and safe and has yieldedpotential benefits in children with cerebral palsy [45].

Interestingly, though age at treatment did not show anysignificant differences in global outcome (𝑛 = 20), it isnoteworthy that within the subgroup of hypoxic-ischemicencephalopathy (HIE, 𝑛 = 8), the non-responders weresignificantly older (65.2 ± 23.1 SD months, 𝑛 = 5) thanthe responders who showed improvements after treatment(Figure 11) (37.3 ± 6.0 SD months, 𝑛 = 3, 𝑃 < 0.01,Chi-Square-test, recalculated from Table 1, [45]). Also, it isconspicuous from Table 1 that in this study the majority(15/20) of conditions possibly related to cerebral palsy did notrespond to treatment. Future clinical trials, which are on theway [10], will have to define clearly which patient will profitand when treatment should be provided for optimum effect.

3.1. Safety Aspects. The children treated for cerebralpalsy by intravenous autologous cord blood transplantationsonly experienced mild adverse effects, including transienthemoglobinuria, nausea, and hypertension in one case [44],mild transient nausea in 2 cases [42], hemoglobinuria plusnausea in 3/20 cases, and hemoglobinuria plus urticaria in2/20 additional cases [45].


(a) (b) (c)

Figure 9: Two-month follow-up: (a) first social smiling of the patient (L. B.) towards his mother and (b), (c) laughing, when played with, 2months after autologous transplantation of cord blood cells (i.e., 4 months and one week after severe brain damage caused by cardiac arrest).(see video S4 in Supplementary Material [44]).

Table 1: Therapeutic responses to autologous cord blood infusion according to clinical characteristics and infused TNC counts. This paperis available online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369209/ [45].

UPN Sex Age (Mo) BW (Kg) TNC (107/kg) Dx Tx responseType GA Possible causes DDST II PEDI GMFCS MACS Overall

1 M 80 13 5.38 Quad Full Unknown N Y N N N2 F 24 10 6.72 Quad Full HIE, PVL N N Y N N3 F 91 14 10.92 Quad Full Unknown N Y N N N4 F 91 19.5 2.87 Quad Full HIE, MAS N N N N N5 F 82 18.1 4.36 Di Full Unknown N Y N N N6 F 28 7.2 9.58 Quad Full Unknown N N N N N7 M 31 11.2 5.72 Quad Full Strep meningitis N N N N N8 F 71 21.4 2.89 Hemi Full Polymicrogyria Y Y N N Y9 M 43 16.4 0.6 Hemi Preterm HIE, PVL Y Y N Y Y10 F 75 9.4 10.63 Quad Full HIE, MAS N N N N N11 F 53 15.3 5.88 Hemi Full Unknown N Y N N Y12 F 40 12.7 2.44 Hemi Preterm HIE, PVL N Y N Y Y13 M 29 10.8 6.85 Di Preterm HIE, PVL Y Y N N Y14 M 67 15 5.26 Quad Full Unknown N N N N N15 M 78 20 5.14 Hemi Full HIE, ICH, Infarction Y Y N N N16 F 71 17.9 2.86 Di Full Unknown N Y N N N17 F 58 11.6 15.65 Quad Preterm HIE, PVL N Y N N N18 M 29 11.3 0.71 Quad Full Unknown N Y N N N19 F 30 11.5 3.29 Hemi Full MCA infarction N N N N N20 M 23 10.9 2.25 Quad Full Unknown N Y N N NUPN: unique patient number, BW: body weight, TNC: total nucleated cells, Dx: diagnosis, Tx: treatment, GA: gestational age, DDST II: Denver developmentalscreening test II, PEDI: pediatric evaluation of disability inventory, GMFCS: GrossMotor Function Classification System,MACS:Manual Ability ClassificationSystem, Quad: quadriplegic, Di: diplegic, Hemi: hemiplegic, Full: full term, HIE: hypoxic ischemic encephalopathy, PVL: periventricular leukomalacia, MAS:meconium aspiration pneumonia, Strep: streptococcal, ICH: intracranial hemorrhage, MCA: middle cerebral artery, N: no, and Y: yes.

The largest retrospective study on safety and feasibilityof intravenous infusion of autologous cord blood, in which184 children with acquired neurologic disorders received 198cord blood infusions (there are no neurological outcomedata available from this study), reports on only 3 (1,5%)patients showing adverse effects [46]. These patients pre-sented infusion reactions, all responding to medical therapyand stopping the infusion. All cord blood units were thawedand washed in dextran-albumine, and premedication withacetaminophen, diphenhydramine, and methylprednisolonewas provided. Interestingly, these authors report on postthaw

sterility cultures that were positive in 7.6% of the infusedcord blood units without causing infections in the patients,though antibiotics were not given. Intravenous infusionslasted 15–20minutes and iv-fluids were administered at twicemaintenance for 2 to 4 hours after cord blood infusion.

Vital signs and pulse-oximetry were monitored every5 minutes during infusion and every 30 minutes for 2to 4 hours after infusion [46]. Thus, on the basis of theavailable information, autologous cord blood transfusion canbe considered a safe and feasible treatment. However, wehave to bear in mind that the effective dose and timing of


Figure 10: 4.5-year follow-up. The boy (L. B.) has now enteredprimary school at the age of 7 and 4.5 years after transplantation ofautologous cord blood after global hypoxic-ischemic brain damagecaused by cardiac arrest followed by a quadriplegic persistent vege-tative state. He is still using a posterior gait trainer for ambulation.(Follow-up at 2 years see video S5, S6 in Supplementary Material[44]).

administration are not known and side effects are almostalways dose dependent.

3.2. Future Challenges. In order to avoid giving false hopesto patients and their families, it will be of utmost impor-tance for ongoing and future clinical trials [10] to definethe groups of brain disorders responding to autologouscord blood transplantation and also to define the respectivetherapeutic windows to provide the optimum timing fortreatment of infantile cerebral palsy. Conversely, to maximizethe benefit for responders, risk groups need to be defined,such as children presenting hypoxic-ischemic encephalopa-thy and/or very low birth weight infants showing evidenceof brain damage, for example, periventricular leukomalacia.Also, sophisticated logistics have to be developed to provideeffective treatment “on-site” shortly after the insult to preventrather than to treat cerebral palsy, perhaps combined withhypothermic neuroprotection.This proposed ambitious “on-site” emergency treatment paradigm is a worthwhile chal-lenge for tertiary perinatal centers, which, above all, requires achange in cord blood banking policy, in that autologous cordblood banking becomes the rule rather than the exception.Once implemented, this new and causative treatment optionoffers the historic opportunity for obstetricians, neonatol-ogists, and neuropediatricians to combat infantile cerebralpalsy effectively for the first time.

4. Conclusions

From an experimental point of view, treatment for acutehypoxic-ischemic brain damage using mononuclear cells

90

67.5

45

22.5

0

Age

(mon

ths)

Non-responder ResponderResponse to cord blood treatment of CP

∗∗

Mean ± SD, ∗∗P < 0.01, 𝜒2

Figure 11: The success of autologous cord blood treatment inchildren with CP caused by hypoxic-ischemic encephalopathydepends on age. Recalculated from Lee et al., Table 1 [45], (HIE,8/20, 65.2 ± 23.1 SD months, 𝑛 = 5 versus 37.3 ± 6.0 SDmonths, 𝑛 = 3, ∗∗𝑃 < 0.01, Chi-Square-test). The paper fromwhich the data for recalculation were derived is available online at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369209/.

from human umbilical cord blood was shown to be effective,at least in the model that we and others employed. Also,insights in some important aspects regarding potentialmech-anisms and modes of action involved have been gathered.However, since there is virtually no information neither onthe optimum amount of cells needed nor on the ideal timingof transplantation after the insult to be effective, future workshould also focus on these clinically important questions.

Froma clinical point of view, intravenous autologous cordblood therapy for infantile cerebral palsy is safe, however,based on the preliminary uncontrolled clinical data available,it appears only to be effective in certain cases. It is importantto notice that in the majority of uncontrolled cases it was noteffective. Future work and ongoing clinical trials primarilymust define both the groups of brain disorders respondingand the therapeutic window, in which autologous cord bloodtherapy may be effective, in order to avoid giving false hopesto the patients and their families. Time matters—in severalrespects.

Conflict of Interests

The author declares that he has no conflict of interests.

Acknowledgments

The preclinical work of the author (A. Jensen) was sup-ported by Grants from the Stem Cell Network North Rhine-Westphalia (KNW NRW 315/2002), Germany; Medical Fac-ulty Ruhr-University Bochum FoRUM (356/2002, 431/2004);Public Prosecutor’s Office Bochum (6KLs 350Js 1/08(101)).


References

[1] V. Kancherla, D. D. Amendah, S. D. Grosse,M. Yeargin-Allsopp,and K. van Naarden Braun, “Medical expenditures attributableto cerebral palsy and intellectual disability among Medicaid-enrolled children,” Research in Developmental Disabilities, vol.33, no. 3, pp. 832–840, 2012.

[2] I. Novak, M. Hines, S. Goldsmith, and R. Barclay, “Clinicalprognostic messages from a systematic review on cerebralpalsy,” Pediatrics, vol. 130, no. 5, pp. e1285–e1312, 2012.

[3] A. Struck, M. Almaazmi, H. Bode et al., “Neurodevelopmentaloutcome of very low birth weight infants born at the PerinatalCentre in Ulm, Germany,” Zeitschrift fur Geburtshilfe undNeonatologie, vol. 217, no. 2, pp. 65–71, 2013.

[4] M. Irazabal, F. Marsa, M. Garcıa et al., “Family burden relatedto clinical and functional variables of people with intellectualdisability with and without a mental disorder,” Research inDevelopmental Disabilities, vol. 33, no. 3, pp. 796–803, 2012.

[5] Centers for Disease Control and Prevention (CDC), “Economiccosts associated withmental retardation, cerebral palsy, hearingloss, and vision impairment—United States,” Morbidity andMortality Weekly Report, vol. 53, pp. 57–59, 2003.

[6] C. de Duve, T. de Barsy, B. Poole, A. Trouet, P. Tulkens, and F.van Hoof, “Commentary. Lysosomotropic agents,” BiochemicalPharmacology, vol. 23, no. 18, pp. 2495–2531, 1974.

[7] D. T. Harris, “Non-haematological uses of cord blood stemcells,”TheBritish Journal of Haematology, vol. 147, no. 2, pp. 177–184, 2009.

[8] J. Kurtzberg, “Update on umbilical cord blood transplantation,”Current Opinion in Pediatrics, vol. 21, no. 1, pp. 22–29, 2009.

[9] K. Rosenkranz and C. Meier, “Umbilical cord blood cell trans-plantation after brain ischemia—from recovery of function tocellular mechanisms,” Annals of Anatomy, vol. 193, no. 4, pp.371–379, 2011.

[10] J. Carroll, “Human cord blood for the hypoxic-ischemicneonate,” Pediatric Research, vol. 71, no. 4, part 2, pp. 459–463,2012.

[11] K. Min, J. Song, J. Y. Kang et al., “Umbilical cord blood therapypotentiated with erythropoietin for children with cerebralpalsy: a double-blind, randomized, placebo-controlled trial,”Stem Cells, vol. 31, no. 3, pp. 581–591, 2013.

[12] J. M. M. Gijtenbeek, M. J. van den Bent, and C. J. Vecht,“Cyclosporine neurotoxicity: a review,” Journal of Neurology,vol. 246, no. 5, pp. 339–346, 1999.

[13] Y. Garnier, H. M. Vaihinger, J. Middelanis, O. Brustle, and A.Jensen, “Cerebral ischemia and umbilical stem cell transplanta-tion in chronically prepared fetal sheep,” in Proceedings of the1st International Meeting of the Stem Cell Network, p. 10, NorthRhine-Westphalia, Germany, 2002.

[14] J. Middelanis, H. M. Vaihinger, Y. Garnier, K. Gottmann, H.Dinse, and A. Jensen, “A model of neonatal cerebral ischemiain rats (“levine”) to study neuroprotection and neuroregenera-tion,” in Proceedings of the 1st International Meeting of the StemCell Network, p. 11, North Rhine-Westphalia, Germany, 2002.

[15] A. Jensen, H. Vaihinger, and C. Meier, “Perinatal braindamage—from neuroprotection to neuroregeneration usingcord blood stem cells,” Medizinische Klinik, vol. 98, no. 2, pp.22–26, 2003.

[16] B. Clancy, B. L. Finlay, R. B. Darlington, and K. J. S. Anand,“Extrapolating brain development from experimental species tohumans,” NeuroToxicology, vol. 28, no. 5, pp. 931–937, 2007.

[17] C. Meier, J. Middelanis, B. Wasielewski et al., “Spastic paresisafter perinatal brain damage in rats is reduced by human cordblood mononuclear cells,” Pediatric Research, vol. 59, no. 2, pp.244–249, 2006.

[18] M. Castillo-Melendez, T. Yawno, G. Jenkin, and S. L. Miller,“Stem cell therapy to protect and repair the developing brain:a review of mechanisms of action of cord blood and amnionepithelial derived cells,” Frontiers in Neuroscience, vol. 7, article194, pp. 1–14, 2013.

[19] O. Dammann andA. Leviton, “Infection remote from the brain,neonatalwhitematter damage, and cerebral palsy in the preterminfant,” Seminars in Pediatric Neurology, vol. 5, no. 3, pp. 190–201, 1998.

[20] Y. Fujita, M. Ihara, T. Ushiki et al., “Early protective effect ofbone marrow mononuclear cells against ischemic white matterdamage through augmentation of cerebral blood flow,” Stroke,vol. 41, no. 12, pp. 2938–2943, 2010.

[21] M. Cao, J. H. Wang, Z. J. Dai et al., “Topological organizationof the human brain functional connectome across the lifespan,”Developmental Cognitive Neuroscience, vol. 7, pp. 76–93, 2014.

[22] S. Neuhoff, J. Moers, M. Rieks et al., “Proliferation, differenti-ation, and cytokine secretion of human umbilical cord blood-derived mononuclear cells in vitro,” Experimental Hematology,vol. 35, no. 7, pp. 1119–1131, 2007.

[23] J. Chen, P. R. Sanberg, Y. Li et al., “Intravenous administrationof human umbilical cord blood reduces behavioral deficits afterstroke in rats,” Stroke, vol. 32, no. 11, pp. 2682–2688, 2001.

[24] H. Y. Liu, Q. J. Zhang, H. J. Li, and Z. C. Han, “Effectof intracranial transplantation of CD34+ cells derived fromhuman umbilical cord blood in rats with cerebral ischemia,”Chinese Medical Journal, vol. 119, no. 20, pp. 1744–1748, 2006.

[25] B.Wasielewski, A. Jensen, A. Roth-Harer, R. Dermietzel, and C.Meier, “Neuroglial activation and Cx43 expression are reducedupon transplantation of human umbilical cord blood cells afterperinatal hypoxic-ischemic injury,”Brain Research, vol. 1487, pp.39–53, 2012.

[26] K. Rosenkranz, S. Kumbruch, K. Lebermann et al., “Thechemokine SDF-1/CXCL12 contributes to the “homing” ofumbilical cord blood cells to a hypoxic-ischemic lesion in therat brain,” Journal of Neuroscience Research, vol. 88, no. 6, pp.1223–1233, 2010.

[27] L. Jiang, M. Newman, S. Saporta et al., “MIP-1𝛼 and MCP-1inducemigration of humanumbilical cord blood cells inmodelsof stroke,” Current Neurovascular Research, vol. 5, no. 2, pp. 118–124, 2008.

[28] M. Geißler, H. R. Dinse, S. Neuhoff, K. Kreikemeier, and C.Meier, “Human umbilical cord blood cells restore brain damageinduced changes in rat somatosensory cortex,” PLoS ONE, vol.6, no. 6, Article ID e20194, 2011.

[29] E. J. Neafsey, E. L. Bold, G. Haas et al., “The organization ofthe rat motor cortex: a microstimulation mapping study,” BrainResearch, vol. 396, no. 1, pp. 77–96, 1986.

[30] A. Horvat, F.-W. Schwaiger, G. Hager et al., “A novel rolefor protein tyrosine phosphatase SHP1 in controlling glialactivation in the normal and injured nervous system,” Journalof Neuroscience, vol. 21, no. 3, pp. 865–874, 2001.

[31] C. A. Beamer, D. M. Brooks, and D. I. Lurie, “Motheaten(me/me) mice deficient in SHP-1 are less susceptible to focalcerebral ischemia,” Journal of Neuroscience Research, vol. 83, no.7, pp. 1220–1230, 2006.

[32] D. Burtrum and F. S. Silverstein, “Hypoxic-ischemic braininjury stimulates glial fibrillary acidic protein mRNA and


protein expression in neonatal rats,” Experimental Neurology,vol. 126, no. 1, pp. 112–118, 1994.

[33] C. A. Wishcamper, D. M. Brooks, J. D. Coffin, and D. I.Lurie, “Focal cerebral ischemia upregulates SHP-1 in reactiveastrocytes in juvenile mice,” Brain Research, vol. 974, no. 1-2, pp.88–98, 2003.

[34] T. Nakase, Y. Yoshida, and K. Nagata, “Enhanced connexin43 immunoreactivity in penumbral areas in the human brainfollowing ischemia,” GLIA, vol. 54, no. 5, pp. 369–375, 2006.

[35] I. Shaked, Z. Porat, R. Gersner, J. Kipnis, and M. Schwartz,“Early activation of microglia as antigen-presenting cells corre-lates with T cell-mediated protection and repair of the injuredcentral nervous system,” Journal of Neuroimmunology, vol. 146,no. 1-2, pp. 84–93, 2004.

[36] A. D. Bachstetter, M. M. Pabon, M. J. Cole et al., “Peripheralinjection of human umbilical cord blood stimulates neurogen-esis in the aged rat brain,” BMC Neuroscience, vol. 9, article 22,2008.

[37] K. Rosenkranz, S. Kumbruch, M. Tenbusch et al., “Transplan-tation of human umbilical cord blood cells mediated beneficialeffects on apoptosis, angiogenesis and neuronal survival afterhypoxic-ischemic brain injury in rats,” Cell and Tissue Research,vol. 348, no. 3, pp. 429–438, 2012.

[38] B. H. Han and D. M. Holtzman, “BDNF protects the neonatalbrain from hypoxic-ischemic injury in vivo via the ERK path-way,” Journal of Neuroscience, vol. 20, no. 15, pp. 5775–5781,2000.

[39] K. Jin, Y. Zhu, Y. Sun, X. O. Mao, L. Xie, and D. A. Greenberg,“Vascular endothelial growth factor (VEGF) stimulates neuro-genesis in vitro and in vivo,”Proceedings of theNational Academyof Sciences of the United States of America, vol. 99, no. 18, pp.11946–11950, 2002.

[40] K. Muramatsu, A. Fukuda, H. Togari, Y. Wada, and H. Nishino,“Vulnerability to cerebral hypoxic-ischemic insult in neonatalbut not in adult rats is in parallel with disruption of the blood-brain barrier,” Stroke, vol. 28, no. 11, pp. 2281–2289, 1997.

[41] S. Fukuhara, K. Sako, T. Minami et al., “Differential function ofTie2 at cell-cell contacts and cell-substratum contacts regulatedby angiopoietin-1,” Nature Cell Biology, vol. 10, no. 5, pp. 513–526, 2008.

[42] K. I. Papadopoulos, S. S. S. Low, T. C. Aw, and T. Chantaro-janasiri, “Safety and feasibility of autologous umbilical cordblood transfusion in 2 toddlers with cerebral palsy and the roleof low dose granulocyte-colony stimulating factor injections,”Restorative Neurology and Neuroscience, vol. 29, no. 1, pp. 17–22,2011.

[43] A. Jensen, “First therapy of cerebral palsy caused by hypoxic-ischemic brain damage in a child after cardiac arrest? Individualtreatment by transplantation of autologous cord blood stemcells,” Regenerative Medizin, vol. 4, no. 1, pp. 30–31, 2011.

[44] A. Jensen and E. Hamelmann, “First autologous cell therapyof cerebral palsy caused by hypoxic-ischemic brain damagein a child after cardiac arrest—individual treatment with cordblood,” Case Reports in Transplantation, vol. 2013, Article ID951827, 6 pages, 2013.

[45] Y.-H. Lee, K. V. Choi, J. H. Moon et al., “Safety and feasibilityof countering neurological impairment by intravenous admin-istration of autologous cord blood in cerebral palsy,” Journal ofTranslational Medicine, vol. 10, article 58, pp. 1–11, 2012.

[46] J. Sun, J. Allison, C. McLaughlin et al., “Differences in qualitybetween privately and publicly banked umbilical cord blood

units: a pilot study of autologous cord blood infusion in childrenwith acquired neurologic disorders,” Transfusion, vol. 50, no. 9,pp. 1980–1987, 2010.

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

review article autologous cord blood therapy for infantile...

Documents